Self-Study Modules on Tuberculosis

Infectiousness 

and Infection Control

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Introduce Module 5

Module 5 – Infectiousness and Infection Control

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Module 5: Objectives

At completion of this module, learners will be able to:

Describe the factors that determine the infectiousness of a TB patient

Describe the main goals of a TB infection-control program

Describe the three levels of control measures that are the basis of an effective TB infection-control program

Describe the purpose and the characteristics of a TB airborne infection isolation (AII) room

Describe the circumstances when personal respirators should be used

State objectives of presentation

Objectives - Module 5, p. 1

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Module 5 – Infectiousness and Infection Control

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Infectiousness

TB Infection Control

TB Infection Control Measures

TB Risk Assessment

Infection Control in Nontraditional Facility-Based Settings

TB Infection Control in the Home

Case Studies

Module 5: Overview

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Review slide content

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Infectiousness

Introduce section

Ask participants which factors are associated with infectiousness

Infectiousness - Module 5, pp. 4-5

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Module 5 – Infectiousness and Infection Control

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Infectiousness is directly related to number of tubercle bacilli TB patients expel into air

TB patients generally expel more tubercle bacilli if their cough produces a lot of sputum

Only people with TB of the lungs, airway, or larynx are infectious 

Infectiousness (1)

Review slide content

Infectiousness - Module 5, pp. 4-5

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Module 5 – Infectiousness and Infection Control

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Infectiousness (2)

Factors generally associated with infectiousness:
| Presence of cough                   | Not covering mouth   when coughing                                 |
|-------------------------------------|--------------------------------------------------------------------|
| Cavity in the lung                  | Not receiving adequate   treatment or prolonged            illness |
| Acid-fast bacilli on   sputum smear | Undergoing cough   inducing procedures                             |
| TB of lungs, airway, or   larynx    | Positive sputum cultures                                           |

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Review slide content

Infectiousness - Module 5, pp. 4-5

Module 5 – Infectiousness and Infection Control

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Infectiousness (3)

Infectiousness appears to decline rapidly after adequate treatment is started; however:

How quickly infectiousness declines varies from patient to patient (weeks to months) 

Patients with drug-resistant TB may not respond to initial drug regimen; meaning they may remain infectious for longer

Review slide content

Infectiousness - Module 5, pp. 4-5

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Module 5 – Infectiousness and Infection Control

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Patients can be considered non-infectious when they meet all of the following criteria:

Received adequate treatment for 2 weeks or longer

Symptoms have improved

Three consecutive negative sputum smears from sputum collected in 8 to 24 hour intervals (at least one early morning specimen)

Infectiousness (4)

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Review slide content

Infectiousness - Module 5, pp. 4-5

Module 5 – Infectiousness and Infection Control

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Infectiousness (5)

Children are less likely than adults to be infectious

Children generally do not produce a lot of sputum when they cough

Young children can still transmit TB if they exhibit signs of infectiousness

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Before showing slide, ask participants if children are more or less likely than adults to be infectious 

Review slide content 

Explain that children can transmit TB to others if they have signs of infectiousness, such as a positive AFB smear or cavity in their lung 

Infectiousness - Module 5, pp. 4-5

Module 5 – Infectiousness and Infection Control

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InfectiousnessStudy Question 5.1

	List 7 factors that affect the infectiousness of a TB patient. 

Presence of a cough

Chest x-ray showing cavity in lung

Positive acid-fast bacilli sputum smear result

TB of lungs, airway, or larynx

Patient not covering mouth or nose when coughing

Not receiving adequate treatment or having prolonged illness

Undergoing cough-inducing procedures

Introduce study questions 

Ask participants to turn to p. 6 (if participants have print-based modules) 

Read question 

Ask participants for answers 

Answers - Module 5, p. 37

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Module 5 – Infectiousness and Infection Control

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InfectiousnessStudy Question 5.2

	Why does the site of disease affect the infectiousness of a TB patient? 

Usually only people with pulmonary or laryngeal TB are infectious.  These people may be coughing and expelling tubercle bacilli into air.

People with extrapulmonary TB are generally not infectious

Read question 

Ask participants for answers 

Answers - Module 5, p. 37

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Module 5 – Infectiousness and Infection Control

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	When can a TB patient be considered noninfectious?  List all 3 criteria. 

		When they meet all of the following criteria:

Received adequate TB treatment for a minimum of 2 weeks

Symptoms have improved 

3 consecutive negative sputum smears from sputum collected in 8-24 hour intervals (one being early morning specimen)

Infectiousness Study Question 5.3

Read question 

Ask participants for answers

Answers - Module 5, p. 37

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TB Infection Control

Introduce section

TB Infection Control - Module 5, pp. 8-35

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Module 5 – Infectiousness and Infection Control

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Infection control is an important strategy to prevent the spread of TB

Several outbreaks of TB in health care settings, including multidrug-resistant TB (MDR TB) and extensively drug-resistant TB (XDR TB), have occurred

All health care and congregate settings should implement TB infection-control measures

TB Infection Control (1)

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Review slide content

TB Infection Control - Module 5, p. 8

Module 5 – Infectiousness and Infection Control

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TB is most likely to be transmitted when health care workers (HCWs) and patients come in contact with persons who:

Have unsuspected TB disease

Are not receiving adequate treatment

Have not been isolated from others

TB Infection Control (2)

Review slide content 

Explain that TB can be transmitted in just about any setting but that it is most likely to be transmitted in health care settings with these three characteristics 

TB Infection Control - Module 5, p. 8

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Module 5 – Infectiousness and Infection Control

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TB Infection Control (3)Role of the Health Department

Health department TB control programs should:

Ensure each of their clinics develop a TB infection-control program

Provide consultation about TB infection control to other health care and congregate settings

Review slide content 

TB Infection Control - Module 5, p. 9

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Module 5 – Infectiousness and Infection Control

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TB Infection Control (4) Role of the Health Department

Health departments should specifically assist health care settings with:

Understanding infection control principles

Reporting confirmed or suspected TB cases

Conducting contact investigations 

Ensuring a plan for TB patients to receive follow-up care after discharge

Conducting risk assessments, testing, surveillance, and outbreak investigations

Planning and implementation of TB control activities

Review slide content 

Explain that health departments should work closely with health care facilities to help them report confirmed or suspected TB cases as quickly as possible 

TB Infection Control - Module 5, p. 9

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Module 5 – Infectiousness and Infection Control

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TB Infection-Control Program (1)

Main goals of a TB infection-control program are to ensure early and prompt:

Detection of TB disease 

Airborne precautions (e.g., isolation of people who have or are suspected of having TB disease)

Treatment of people who have or are suspected of having TB disease 

Review slide content 

TB Infection Control Program - Module 5, p. 10

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Module 5 – Infectiousness and Infection Control

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HCWs should suspect TB disease in anyone with any of these symptoms:

Persistent cough

Chest pain

Bloody sputum

Weight loss or loss of appetite

Fever

Chills

Night sweats

TB Infection-Control Program (2)Detection of TB disease

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Review slide content 

Explain that in areas where TB is common staff at health care facilities should stay alert for TB; especially staff at public health and community clinics 

TB Infection-Control Program - Module 5, p. 10

Module 5 – Infectiousness and Infection Control

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When a health care worker suspects that a patient has TB disease, the patient should be:

Placed in an area away from other patients and evaluated

Given a surgical mask to wear

Given tissues and asked to cover nose and mouth when coughing or sneezing

TB Infection-Control Program (3) Detection of TB disease

Before showing slide, ask what a health care worker should do if they suspect a patient has TB disease 

Review slide content 

TB Infection Control Program - Module 5, p. 10

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Module 5 – Infectiousness and Infection Control

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Airborne precautions should be taken for any person who has signs or symptoms of TB disease

If facility has an AII room, TB suspects and TB patients should be placed there

Health care settings, such as TB clinics, should implement a respiratory-protection program

TB Infection-Control Program (4)Airborne Precautions

Before showing slide, ask what airborne precautions should be taken for a person who has signs or symptoms of TB disease 

Review slide content 

Explain that if a facility does not have an AII room, patients who have or are suspected of having TB should be placed in an area away from other patients 

Explain that for settings other than clinics, patients with suspected TB should be promptly referred for a medical evaluation 

TB Infection Control Program - Module 5, pp. 11-12

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Module 5 – Infectiousness and Infection Control

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Patients diagnosed with TB should start treatment immediately

DOT should be used to ensure adherence

TB Infection-Control Program (5)Treatment

Review slide content 

Emphasize that DOT is the best way to ensure adherence to treatment 

TB Infection Control Program - Module 5, p. 12

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Module 5 – Infectiousness and Infection Control

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TB Infection ControlStudy Question 5.4

	Under what circumstances is TB most likely to be transmitted in health care facilities?  

	TB is most likely to be transmitted when health care workers and patients come into contact with persons who:

Have unsuspected TB disease

Are not receiving adequate treatment

Have not been isolated from others

Introduce study questions 

Ask participants to turn to p. 13 (if participants have print-based modules) 

Read question 

Ask participants for answers 

Answers - Module 5, p. 37

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Module 5 – Infectiousness and Infection Control

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TB Infection ControlStudy Question 5.5

	How can the health department assist health care settings in preventing the spread of TB? 

The health department can help health care facilities with:

Understanding infection control principles

Reporting confirmed or suspected TB cases

Conducting contact investigations

Ensuring there is a plan for TB patients to receive follow-up care after they are discharged

Risk assessments, testing, surveillance, and outbreak investigations

Planning and implementing TB control activities

Read question 

Ask participants for answers 

Answers - Module 5, p. 38

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Module 5 – Infectiousness and Infection Control

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	What are the main goals of a TB infection-control program? 

		The main goals are to detect TB disease early 	and to promptly isolate and treat people who 	have TB disease.

TB Infection ControlStudy Question 5.6

Read question 

Ask participants for answers 

Answers - Module 5, p. 38

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Module 5 – Infectiousness and Infection Control

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	What would make a health care worker suspect that a patient has TB disease? 

Persistent cough

Bloody sputum

Weight loss or loss of appetite

Fever

Night sweats

TB Infection ControlStudy Question 5.7

Read question 

Ask participants for answers 

Answers - Module 5, p. 38

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Module 5 – Infectiousness and Infection Control

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	What should be done when a health care worker suspects that a patient has TB disease? 

	The patient should be

Placed in an area away from other patients and evaluated

Given surgical mask to wear

Given tissues and asked to cover nose and mouth when coughing or sneezing

	Patients who are diagnosed with TB should start appropriate treatment at once

TB Infection ControlStudy Question 5.8

Read question 

Ask participants for answers 

Answers - Module 5, p. 38

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TB Infection Control TB Infection Control Measures

Introduce section  

TB Infection Control Measures - Module 5, p. 16

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Module 5 – Infectiousness and Infection Control

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TB Infection Control Measures (1)Hierarchy of Infection Control

Respiratory Protection

Administrative Controls

Environmental Controls

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Explain that there are three levels of infection control 

Review slide content 

TB Infection Control Measures - Module 5, p. 16

Module 5 – Infectiousness and Infection Control

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Three levels of control measures:

Administrative controls:  managerial measures to reduce risk of exposure to M. tuberculosis

Environmental controls:  engineering systems to prevent the spread of and reduce the concentration of infectious M. tuberculosis droplet nuclei in air

Respiratory-protection controls:  personal protection to further minimize risk for exposure to M. tuberculosis 

TB Infection Control Measures (2)

Review slide content 

TB Infection Control Measures - Module 5, p. 16

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TB Infection Control TB Infection Control MeasuresAdministrative Controls

Introduce section 

Ask participants what types of administrative controls should be used 

Administrative Controls - Module 5, pp. 17-19

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Module 5 – Infectiousness and Infection Control

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Administrative controls:

First and most important level of TB infection-control program

Goal is to reduce risk of exposure to persons who might have TB disease

Administrative Controls (1)

Review slide content 

Administrative Controls - Module 5, p. 17

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Administrative control activities:

Assigning someone responsibility for TB infection control

Developing and implementing a written TB infection control plan

Conducting a TB risk assessment

Ensuring availability of prompt laboratory processing, testing, and reporting of results

Administrative Controls (2)

Review slide content 

Explain that a TB risk assessment consists of evaluating the risk of transmission 

Explain that an infection control plan should specify policies and practices to ensure prompt detection, isolation, and treatment or transfer of persons who have suspected or confirmed disease 

Explain that laboratory services help to determine if patients are still infectious and if they need to remain in an AII room 

Administrative Controls - Module 5, p. 17

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Module 5 – Infectiousness and Infection Control

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Administrative control activities (cont.):

Implementing effective work practices for managing patients who may have TB 

Ensuring proper cleaning and sterilization or disinfection of equipment

Educating, training, and counseling HCWs about TB

Testing and evaluating workers who are at risk for TB or may be exposed to TB

Administrative Controls (3)

Review slide content 

Explain that all health care workers should be educated about basic TB concepts, infection control, and the importance of testing programs 

Explain that TB testing programs can protect both workers and patients. Each health care setting should determine if and how often serial testing is offered depending upon the risk of TB transmission in their setting 

Administrative Controls - Module 5, p. 18

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Module 5 – Infectiousness and Infection Control

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Administrative control activities (continued):

Applying epidemiology-based prevention principles

Using posters to remind patients of proper cough etiquette

Coordinating efforts between health departments and high risk settings

Administrative Controls (4)

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Review slide content 

Emphasize that state or local health department TB control programs and high-risk health care and congregate settings should establish regular communication 

Administrative Controls - Module 5, p. 19

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TB Infection Control TB Infection Control MeasuresEnvironmental Controls

Introduce section 

Environmental Controls - Module 5, pp. 19-22

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Module 5 – Infectiousness and Infection Control

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Second level of infection-control program

Consist of technologies that are designed to prevent the spread and reduce the concentration of TB in the air

Ventilation technologies

High efficiency particulate air filtration (HEPA)

Ultraviolet germicidal irradiation (UVGI)

Environmental Controls

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Review slide content 

Explain that the specifics of environmental controls will differ for each health care setting 

Environmental Controls - Module 5, p. 19

Module 5 – Infectiousness and Infection Control

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Ventilation is the movement of air in a building and the replacement of air inside with air from outside 

Ventilation technologies include:

Natural ventilation

Mechanical ventilation

Ventilation Technologies (1)

Review slide content 

State that when fresh air enters a room, it dilutes the concentration of particles in room air, such as droplet nuclei containing M. tuberculosis 

Environmental Controls - Module 5, p. 20

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Doors and windows should be open 

Fans can be used to distribute air

HCW should sit near fresh air source

Can be useful for nontraditional settings that do not have a central ventilation system

Ventilation Technologies (2)

Natural Ventilation

Review slide content 

Explain that natural ventilation relies on open doors and windows to bring in air from the outside 

State that waiting rooms, shelter dormitories, or other rooms in which people congregate should have an operable door, window, or skylight kept open as often as possible 

Environmental Controls - Module 5, p. 19

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Ventilation Technologies (3) Mechanical Ventilation

Refers to the use of technological equipment to circulate and move air

Consists of two types of technologies

Local exhaust ventilation

General ventilation

Should be used by hospitals, TB clinics, and other settings where TB patients are expected

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Review slide content 

Environmental Controls - Module 5, p. 20

Module 5 – Infectiousness and Infection Control

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Ventilation Technologies (4)Mechanical Ventilation

Local exhaust ventilation

Stops airborne contaminants from spreading into general environment

Includes external hoods, booths, and tents

Should be used for cough-inducing procedures

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Review slide content 

Environmental Controls - Module 5, p. 20

Module 5 – Infectiousness and Infection Control

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General ventilation systems:

Dilute contaminated air

Remove contaminated air

Control airflow patterns in patient and procedure rooms (e.g., negative pressure in AII room)

Ventilation Technologies (5)Mechanical Ventilation

Review slide content 

Environmental Controls - Module 5, p. 21

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Module 5 – Infectiousness and Infection Control

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Ventilation Technologies (6)Mechanical Ventilation

AII rooms are designed to prevent spread of droplet nuclei expelled by patient

Negative pressure

Clean air flows from corridors into AII room

Air cannot escape AII room 

Exhausted outdoors or passed through filter

Image credit:  Curry International TB Center

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Explain that in TB clinics, hospitals, and other inpatient settings, patients known or suspected of having TB disease should be placed in an AII room 

Review slide content 

Note that air from AII rooms can be exhausted outdoors because any infectious droplet nuclei will be diluted in the outdoor air and killed by sunlight 

Environmental Controls - Module 5, p. 21

Module 5 – Infectiousness and Infection Control

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HEPA Filters

HEPA filters are special filters used to remove droplet nuclei from air

Must be used when releasing air from:

Local exhaust ventilation booths to surrounding area

AII room to general ventilation system

Image credit: Curry International TB Center

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Review slide content 

Use the image to illustrate how air circulates through the room 

Environmental Controls - Module 5, p. 21

Module 5 – Infectiousness and Infection Control

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UVGI

UVGI is air cleaning technology that consists of lamps that give off UV light, which can kill tubercle bacilli

Should be used with other infection control measures

UV light can be harmful to skin and eyes

Image credit:  Curry International TB Center

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Review slide content 

State that because UV light can be harmful to skin and eyes the lamps must be installed in upper part of rooms or corridors or placed in exhaust ducts 

Environmental Controls - Module 5, p. 22

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TB Infection Control TB Infection Control MeasuresRespiratory-Protection Controls

Introduce section 

Ask what types of respiratory protection controls should be used by the patient and the health care worker 

Respiratory-Protection Controls - Module 5, pp. 22-24

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Third level of infection-control that includes:

Implementing a respiratory-protection program

Training health care workers on respiratory-protection

Educating patients on respiratory hygiene

Respiratory-Protection Controls (1)

Review slide content 

Note that all health care settings that use respiratory-protection controls are required by the Occupational Safety and Health Administration (OSHA) to develop, implement, and maintain a respiratory-protection program 

Explain that respiratory-protection controls reduce the risk of TB transmission in settings where administrative and environmental controls may not fully protect persons against droplet nuclei 

Respiratory-Protection Controls - Module 5, p. 22

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Respiratory-Protection Controls (2) Personal Respirators

Respirators filter out droplet nuclei 

Should be used in:

TB AII rooms

Rooms where cough-inducing or aerosol generating procedures are done

Ambulances transporting infectious TB patients

Homes of infectious TB patients 

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Review slide content 

Respiratory-Protection Controls - Module 5, p. 22

Module 5 – Infectiousness and Infection Control

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Respiratory-Protection Controls (3)Personal Respirators

Important that respirator fits properly:

Fit test used to determine which respirator to wear

User seal check should be done each time a respirator is put on

Health care worker undergoing a fit test

Image credit: Paul Jensen

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Review slide content 

Emphasize that the most important factor to consider when selecting respirator is whether the respirator fits properly 

Explain that the image is of a health care worker undergoing a fit test for a personal respirator 

Respiratory-Protection Controls - Module 5, p. 23

Module 5 – Infectiousness and Infection Control

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Respiratory-Protection Controls (4)Personal Respirators

Respirators that can be used to protect against M. tuberculosis:

Nonpowered respirators with N95, N99, N100, R95, R99, R100, P95, P99, and P100 filters

Powered air-purifying respirators (PAPRs) with high-efficiency filters

Supplied-air respirators

Image credit: Greg Knobloch

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Review slide content 

Explain that the top image shows non-powered respirators 

Explain that the bottom image is of a woman wearing a powered air-purifying respirator (PAPR) 

Respiratory-Protection Controls - Module 5, p. 23

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Important to understand the difference between respirators and surgical masks

Respirators protect individuals from inhaling droplet nuclei

Surgical masks stop droplet nuclei from being exhaled into air by infectious TB patients or suspects

Respiratory-Protection Controls (5)Respirators and Surgical Masks

Review slide content 

Explain that respirators protect individuals from becoming infected with M. tuberculosis and that surgical masks protect individuals from expelling infectious droplet nuclei 

Respiratory-Protection Controls - Module 5, p. 23

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Health care worker wearing a personal respirator 

Respiratory-Protection Controls (6)Respirators

Explain that this image is of a health care worker wearing a personal respirator 

Respiratory-Protection Controls - Module 5, p. 24

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Module 5 – Infectiousness and Infection Control

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Patient wearing a surgical mask

Respiratory-Protection Controls (7)Surgical Masks

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Explain that this image is of a patient wearing a surgical mask 

Emphasize that patients should not wear respirators because respirators are designed to prevent persons from inhaling droplet nuclei 

Respiratory-Protection Controls - Module 5, p. 24

Module 5 – Infectiousness and Infection Control

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	What are the three levels of control that form the basis of a TB infection-control program? 

Administrative controls

Environmental controls

Respiratory-protection controls

TB Infection-ControlStudy Question 5.9

Introduce study questions 

Ask participants to turn to p. 26 (if participants have print-based modules) 

Read question 

Ask participants for answers 

Answers - Module 5, p. 38

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Module 5 – Infectiousness and Infection Control

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Administrative ControlsStudy Question 5.10

	List 5 administrative control measures that should be taken in health care settings to reduce the risk of exposure to persons who may have TB disease. 

Assign responsibility for TB infection control

Conduct TB risk assessment

Develop and implement a written TB infection-control plan

Ensure prompt availability of recommended laboratory processing, testing, and reporting of results

Implement effective work practices for the management of patients 

Ensure proper cleaning, sterilization, or disinfection of equipment

Train and educate health care workers

Test and evaluate health care workers for TB

Apply epidemiology-based prevention principles

Use posters and signs educating and advising respiratory hygiene and cough etiquette

Coordinate efforts with health department and high-risk health care and congregate settings

Read question 

Ask participants for answers 

Answers - Module 5, p. 39

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	Where should sputum induction, bronchoscopy, or other cough-inducing procedures be done? 

 These medical procedures should be done in special AII rooms or sputum induction booths to prevent any droplet nuclei expelled during the procedure from reaching other parts of the facility.

Environmental ControlsStudy Question 5.11

Read question 

Ask participants for answers 

Answers - Module 5, p. 39

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Environmental ControlsStudy Question 5.12

	What is a TB AII room?  What are the important characteristics of an AII room? 

Airborne infection isolation (AII) rooms have special characteristics to prevent spread of droplet nuclei expelled by a TB patient.  They are at negative pressure relative to other parts of the facility, and air from the room is exhausted directly to the outdoors or passed through a filter.

Read question 

Ask participants for answers 

Answers - Module 5, p. 39

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	How do ventilation systems help prevent the spread of TB? 

Ventilation systems maintain negative pressure and exhaust air properly. These systems can also be designed to minimize the spread of TB in other areas of the facility. 

Ventilation Systems Study Question 5.13

Read question 

Ask participants for answers 

Answers - Module 5, p. 40

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Ventilation Systems Study Question 5.14

	Give 4 examples of settings where personal respirators should be used. 

TB AII rooms

Rooms where cough-inducing procedures are done

Ambulances or other vehicles transporting infectious TB patients

Homes of infectious TB patients

Read question 

Ask participants for answers 

Answers - Module 5, p. 40

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	What is the difference in use between a respirator and a surgical mask? 

Respirators protect individuals from inhaling droplet nuclei  

Surgical masks stop droplet nuclei from being exhaled into the air by the person wearing them  

Respiratory Protection-ControlsStudy Question 5.15

Read question 

Ask participants for answers 

Answers - Module 5, p. 40

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TB Infection Control TB Risk Assessment

Introduce section 

TB Risk Assessment - Module 5, pp. 28-30

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Module 5 – Infectiousness and Infection Control

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TB Risk Assessment (1)

Administrative control measure

Helps to inform infection control plan

Determines types of controls needed for setting

Serves as an initial and ongoing monitoring and evaluation tool for infection-control program

Helps determine frequency of employee testing

Explain that every health care and congregate setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis 

Review slide content 

TB Risk Assessment - Module 5, p. 28

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Risk assessment examines many factors, including:

Number of patients with TB disease in setting

Promptness of detection, isolation, and evaluation of patients with suspected or confirmed TB

Evidence of transmission of M. tuberculosis in setting

Community rate of TB disease

TB Risk Assessment (2)

Review slide content 

TB Risk Assessment - Module 5, p. 28

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Low risk

Persons with TB disease are not expected to be encountered

Medium risk

Possible exposure to persons with TB disease

Possible exposure to clinical TB specimens

Potential ongoing transmission

Setting where there is evidence of person-to-person transmission of M. tuberculosis in past year

TB Risk Classification

Explain that the risk level will vary from setting to setting. There are three TB risk classifications 

Review slide content 

TB Risk Assessment - Module 5, p. 28

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| TB Risk Classification         | Frequency for TB Testing                                                                                                                                                       |
|--------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Low Risk                       | Conduct baseline test when health  care worker is hired No further testing needed unless  exposure occurs                                                                      |
| Medium Risk                    | Conduct baseline test when   health care worker is hired  Repeat test annually                                                                                                 |
| Potential Ongoing Transmission | Conduct baseline test when health  care worker is hired Repeat test every 8 to 10 weeks             until there is no evidence of M.   tuberculosis transmission in    setting |

TB Testing Frequency

Explain that TB risk assessment helps to determine the need for a TB testing program and the frequency of the testing 

Review slide content 

TB Risk Assessment - Module 5, p. 30

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TB Infection Control Infection Control in Nontraditional Facility–Based Settings

Introduce section 

Infection Control in Nontraditional Facility-Based Settings - Module 5, pp. 30-32

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Module 5 – Infectiousness and Infection Control

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Nontraditional facility-based settings where TB patients receive care should establish and follow an infection-control program

Includes settings such as:

Nursing homes

Correctional facilities

Homeless shelters

Drug treatment centers

Emergency medical services

Home-based health care

Outreach settings

Special Considerations (1)

Review slide content 

Explain that the main goal should be to detect TB disease early and arrange for isolation and treatment of patients suspected of having TB 

Local health departments and congregate settings should collaborate to provide training and education about TB as well as conducting contact investigations when necessary 

Infection Control in Nontraditional Facility-Based Settings - Module 5, p. 30

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Medical settings within correctional facilities should:

Classify as medium risk or higher

Test all staff annually

Implement a respiratory-protection program with at least one AII room

Special Considerations (2)Correctional Facilities

Review slide content 

Infection Control in Nontraditional Facility-Based Settings - Module 5, pp. 30-31

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Medical settings within correctional facilities should (cont.):

Have inmates with suspected or confirmed TB disease wear surgical mask when transported

Establish and maintain a tracking system for inmate testing and treatment

Special Considerations (3)Correctional Facilities

Review slide content 

State that confidentiality of inmate information should be ensured during testing for signs and symptoms of TB 

Infection Control in Nontraditional Facility-Based Settings - Module 5, p. 31

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Should observe the same TB infection-control measures as outpatient clinics

Several factors in shelter environment can influence likelihood of TB transmission:

Crowdedness of shelter

Ventilation system of shelter

Special Considerations (4)Homeless Shelters

Explain that TB is more common in the homeless population than the general population 

Review slide content 

Infection Control in Nontraditional Facility-Based Settings - Module 5, p. 31

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EMS workers should be included in TB testing program based on risk for the setting

Persons with infectious TB who are transported in ambulance should wear surgical mask

Drivers, health care workers, and other staff should consider wearing a respirator

Ambulance should allow for maximum amount of outdoor air to be circulated in vehicle

Special Considerations (5) Emergency Medical Services (EMS)

Explain that even though the overall risk of transmission of M. tuberculosis in EMS settings is low, there has been documented transmission 

Review slide content 

Infection Control in Nontraditional Facility-Based Settings - Module 5, p. 31

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LTCFs (e.g., hospices and nursing homes) should:

Symptom screen and possibly test new employees and residents

Have administrative and environmental controls IF they accept patients with infectious TB

Persons with TB disease who are non-infectious can stay in LTCFs and do not need AII room

Special Considerations (6)Long-Term Care Facilities (LTCFs)

Review slide content 

Emphasize that patients with suspected or confirmed infectious TB disease should not stay in a long-term care facility unless adequate administrative and environmental controls are in place 

Infection Control in Nontraditional Facility-Based Settings - Module 5, p. 32	

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 TB Infection Control TB Infection Control in the Home

Introduce section 

Ask what type of TB infection control should be used in the home for the 

Family 

Health care worker 

TB Infection Control in the Home - Module 5, pp. 32-33

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TB Infection Control in the Home (1)Patient Returning Home

TB patients and TB suspects may be sent home after starting treatment, even though they may be infectious

Review slide content 

TB Infection Control in the Home - Module 5, p. 32

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TB Infection Control in the Home (2) Patient Returning Home

Criteria for patient to return home:

Follow-up plan has been made with the local TB program

Patient on TB treatment and DOT arranged

No infants or children younger than 5 years of age or persons with immunocompromising conditions in home

Explain that TB patients can return home even if they do not have three negative sputum smears, if certain criteria are met 

Explain that patients with TB disease are allowed to go back home if all of the criteria are met 

Review slide content 

TB Infection Control in the Home - Module 5, p. 32

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Criteria for patient to return home (cont.):

All household members have already been exposed to TB patient

Patient is willing to not travel outside of home until sputum smear results are negative

TB Infection Control in the Home (3) Patient Returning Home

Review slide content 

TB Infection Control in the Home - Module 5, p. 32

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TB patients and members of household should take steps to prevent spread of TB

Patients with TB should be instructed to:

Cover mouth and nose with tissue when coughing or sneezing

Sleep alone

Not have visitors until noninfectious

TB Infection Control in the Home (4) Patient Returning Home

Review slide content 

Note that it is more likely that TB patients transmitted TB to members of their household before their TB was diagnosed and TB started; however, steps should still be taken to prevent the spread of TB in the home when the patient returns 

TB Infection Control in the Home - Module 5, p. 32

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HCWs should:

Be trained in detecting TB signs and symptoms

Take precautions to protect themselves:

Instruct patient to cover mouth when coughing

Wear personal respirator

Collect sputum in well-ventilated areas

Participate in TB testing and prevention programs

TB Infection Control in the Home (5)Health Care Workers (HCWs)

Review slide content 

TB Infection Control in the Home - Module 5, p. 33

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TB Risk AssessmentStudy Question 5.16

	What are 3 different TB risk classifications that can be assigned to health care settings? 

Low risk

Medium risk

Potential ongoing transmission

Introduce study questions 

Ask participants to turn to p. 34 (if participants have print-based modules) 

Read question 

Ask participants for answers 

Answers - Module 5, p. 40

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	Depending on risk classification, how often should health care settings test workers for TB? 

Low Risk Settings 

Conduct TB baseline test when HCW is hired

No further testing needed unless exposure occurs 

Medium Risk Settings

Conduct TB baseline test when HCW is hired

Repeat test annually

Potential Ongoing Transmission

Conduct baseline test when HCW is hired

Repeat test 8-10 weeks until there is no longer evidence of M. tuberculosis transmission in the setting

TB Risk AssessmentStudy Question 5.17

Read question 

Ask participants for answers 

Answers - Module 5, p. 41

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TB Infection Control in the HomeStudy Question 5.18

	What precautions should a health care worker take when visiting the home of a TB patient who may be infectious? 

Instruct patients to cover mouth and nose with a tissue when coughing or sneezing

Wear a personal respirator

Collect sputum specimen in a well-ventilated area

Participate in a TB testing and prevention program

Read question 

Ask participants for answers 

Answers - Module 5, p. 41

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Case Studies

Introduce case studies 

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Module 5: Case Study 5.1

	For each of the following situations, decide whether the patient should be considered infectious or non-infectious, and explain why. 

Read case study 

Ask participants for answers

Case Study 5.1 – Module 5, p. 7

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	Two weeks ago, Mr. Lopez had a sputum smear that was positive; since then no sputum specimens have been tested.  Mr. Lopez started self-administered TB treatment 7 days ago.  He still has a cough.

Module 5: Case Study 5.1Question 5A

Ask participants to turn to p. 7 (if participants have print-based modules) 

Read case study 

Case Study 5.1 – Module 5, p. 7

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Module 5: Case Study 5.1Question 5A: Answer

Mr. Lopez should be considered infectious

Should be given his treatment by DOT to ensure he receives adequate treatment

Does not meet the criteria for noninfectiousness because:

He has been receiving treatment for only 7 days, not 2 weeks

His symptoms have not improved

He does not have 3 consecutive negative sputum smears

Answers - Module 5, p. 42

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Module 5: Case Study 5.1Question 5B

	Ms. Nguyen, a patient with pulmonary TB, has been receiving DOT treatment for 6 weeks and no longer has symptoms of TB.  She has had three sputum smears.  The first one was positive, but the last two were negative.

Read case study question

Ask participants for answers 

Case Study 5.1 – Module 5, p. 7

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Module 5: Case Study 5.1Question 5B: Answer

Ms. Nguyen should be considered infectious until she has 3 consecutive negative sputum smears

She meets the first 2 criteria for noninfectiousness:

Has been receiving treatment for at least 2 weeks

Her symptoms have improved

Answers - Module 5, p. 42

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Module 5: Case Study 5.1Question 5C

	Mr. Martin started DOT treatment for pulmonary TB in April.  His symptoms went away and his sputum smears were negative in May.  However, the outreach worker was unable to locate him on June 5th and has not been able to contact him since that time.  Mr. Martin returned to the TB clinic on August 2nd, and was still coughing.

Read case study question

Ask participants for answers 

Case Study 5.1 – Module 5, p. 7

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Module 5: Case Study 5.1Question 5C: Answer

Mr. Martin, at this point, should be considered infectious

He might have been noninfectious in May, but it appears that he may be infectious again

Has been coughing and has not received adequate treatment since June 4th

Should be evaluated for infectiousness and nonadherence to treatment

Answers - Module 5, p. 42

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Module 5: Case Study 5.2 (1)

	You are checking patients into the TB clinic.  An elderly man comes to the desk and says he was told to come and get checked because one of his friends has TB.  You notice that he looks sick and is coughing frequently.  The waiting room is full of patients, and you know it will probably be more than an hour before the physician can see him. 

Ask participants to turn to p. 15 (if participants have print-based module)

Read case study

Case Study 5.2 – Module 5, p. 15

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Module 5: Case Study 5.2 (2)

What should you do?

Suspect that this man has infectious TB and work with clinical staff to ensure he is evaluated for TB quickly

Give him a surgical mask, instruct him to keep it on, and ask him to cover his mouth and nose when coughing or sneezing.  

Move the man to an area away from other patients right away

Answers - Module 5, p. 43

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Module 5: Case Study 5.3 (1)

	You are sent to deliver directly observed therapy (DOT) to a woman who started treatment last week for suspected pulmonary TB.  Her sputum smear results are not back yet.  You are asked to collect another sputum specimen while you are at the woman’s home. 

Ask participants to turn to p. 35 (if participants have print-based modules)

Read case study

Case Study 5.3 – Module 5, p. 35

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Module 5: Case Study 5.3 (2)

What precautions should you take?

Instruct patient to cover her mouth and nose when she coughs or sneezes. 

Wear a personal respirator when visiting her home. 

Collect sputum in well-ventilated area, away from other household members. 

Participate in a TB testing and prevention program

Answers - Module 5, p. 43

Ask if there are any questions about Module 5 

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